Copyright Ó 2002 Delmar Learning, a Division of Thomson Learningô, Inc

Gerald Jenks

Background scenario

Gerald is a 25-year-old nursing assistant at the Daystar Clinic. He has been on vacation but returns to the clinic a day early, complaining of severe itching in his hair and neck. Two friends, Gene and Julius, who are also scratching, but not as ardently as Gerald, accompany him. They state that they have just come straight to the clinic from the wilderness, where they were backcountry hiking and rock climbing. Vigorously scratching both hands through his bushy hair, Gerald pleads with the nurse to help him to stop the itching.

Interview

Gerald:

"I've been itching like this since yesterday. I can't stand it!"

"We have been out camping and rock climbing since I got off shift last Wednesday."

"I must have gotten into some poison ivy or some bugs."

"It started about the third day we were in the wilderness. The itching was mild for several days, but it was so bad last night that I ripped my clothes off and jumped into the creek. We have been out there a week. We have another week ahead, but forget it!"

"It's kind of a tingling sensation. It started on my right side, right at the base of my hair. Then it just spread all over my head, and my neck."

"The itching was better for awhile, but then it got real bad during the night."

"I'm scratching all over. Even my eyebrows itch."

"I itch, too. Not as bad as Gerald."

"It wasn't very bad until we were driving today."

"My head itches." "Maybe it was itching powder."

"It feels like itching powder. I've had it in my shorts before."

"I don't think it can be poison ivy. We would all be one big rash."

Julius:

"Gerald thought we put itching power in his sleeping bag, but I reminded him that he was scratching on the drive to trailhead after we picked him up from work last week."

"He was really bad last night, so he jumped into the creek."

"He was screaming in that cold water, but it seemed to help the itching."

"He woke us up during the night complaining. He couldn't stop the itching."

"We bagged our trip and packed up at five this morning to come here. We didn't even stop for breakfast."

"Yeah. I itch a little around my ears on the back of my neck, not like Gerald, though."

Examination

Vital signs:

Temperature: 98.4°F Pulse: 78 Respiration rate: 20 Blood pressure: 118/80

Observation:

Gerald has shoulder length hair. Skin on scalp and neck is reddened and dry. Scratch marks from itching are apparent on the back of the neck, forehead, shoulders, and chin. Tiny red spots are scattered on the sides and back of Gerald's head.

As time passes

Later that day, Gerald checks his duty log from his last day at work. His last client was a 9-year-old kid he was helping to bathe in the shower. The chart indicates that the following day the child was observed to be itching. The child was examined and diagnosed with pediculosis. It was determined to be head lice and the child was treated before being sent home. The report indicated that the child's parents were instructed on proper procedures to take at home.

Gerald remembers the bathing session because it was his last duty of the day and he was rushing to get off work. He remembers that the child almost fell while drying off. Gerald remembers throwing the child's towel over his own shoulder so his hands would be free to support the child.

Gerald reports this to the nurse who has already made this diagnosis. The nurse assesses further to determine the nature and possible spread of the problem. Gerald's locker is checked. Since he disposed of his work clothes in the laundry before leaving on vacation, the nurse determines that there was no risk in the shared locker room. The nurse has assessed Gerald's friends and found them to be infested as well. Transmission is likely to have occurred while the trio was sleeping in close quarters in a three-person tent, when they shared baseball caps and raingear, or when they piled their sleeping bags together during the daytime. The nurse determines that it was unlikely that the trio exposed others, concluding that the backcountry-backpacking trip has effectively isolated the trio from exposing others. Clothes, camping gear and their automobile will need to be treated.

Background education

Pediculosis, an infestation of lice, is contagious because the tiny insects spread through direct skin-to-skin contact and through shared clothing and other items. Parasites, lice feed on the skin of the host and lay their eggs in clothes and hair. There are three types of pediculosis--head lice (Pediculosis humanus capitus), body lice (Pediculosis humanus corposis), and pubic lice (Phthirus publis).

Head lice are about two to three millimeters long and are gray-white or gray- brown. They have six legs with claws used for gripping. They move by crawling, and do not fly or jump. A single female can start an infestation. The female head louse lays small eggs (nits) on the scalp at the base of the hair where they are protected, attaching them with a glue-like substance. The nits appear to be white spheres and are commonly found on the hair at the back of the head, neck, and behind the ears. The hair provides a perfect incubation temperature, and the eggs hatch in one to two weeks. Head lice live up to 30 days on the head, but they will not live longer than two to four days away from a host.

Pediculosis can cause intense itching as the lice bite the skin and deposit saliva under the outer skin surface. Itching can be so severe that scratching can cause injury to the skin, and lead to infection. Head lice are contracted through contact with someone with an infestation such as head-to-head or other close contact. Head lice may also be contracted through shared items such as hats, scarves, towels, pillows and bedding. Itching is the primary symptom of head lice infestation. The itching can be mild or severe and is often described as a prickling or tingling sensation. Head lice infestations may be accompanied by a mild fever, muscle aches, and swollen neck glands. An infection may result from broken skin caused by prolonged scratching. To assess for lice, use a magnifying glass and a bright light. Wear gloves and use wooden applicator sticks to move the hair, one section at a time, looking for signs of infestation. Inspect the base of the hair, especially around the ears and in the neck region, looking for the grayish/white nits, which are easier to see than the live lice against dark hair. The nits appear to be like dandruff, clinging to the hair shaft, but are more difficult to remove than dandruff. Remember that lice are communicable, so be careful not to provide opportunities for transferring the lice to other humans, articles of clothing, furniture, pillows or other surfaces.

To treat a head lice infestation, all lice and nits must be killed or removed, then the hair combed with a lice comb to remove nits that may have survived the treatment process. If the nits are not removed, the nits may hatch and cause reinfestation. Shampoos available over the counter and through a prescription contain pesticides that kill adult lice. It is recommended that the person's physician be contacted first to find out if the client has asthma, allergies, or neurological conditions. Always follow the manufacturer's instructions. Disposable gloves should be worn. Eyebrows need to be treated as well as the hair. The client should be advised that another treatment is necessary in a week to kill any missed nits that have hatched.

Pesticide-free alternative treatments are available, although not frequently used. Alternatives call for the use of products that coat the lice and kill them by suffocation. Drenching the hair with vegetable oil, mineral oil, olive oil, petroleum jelly, or mayonnaise are alternatives to pesticide shampoos. Apply them liberally to the hair and then cover the head with a shower cap for up to eight hours. Then rinse with a mild degreasing dishwashing soap or baby oil. Following the use of suffocants or shampoo, the hair should be rinsed well. Dead lice and nits need to be combed out with a fine-tooth comb. Disposable gloves should be worn.

Cleaning and removing lice from clothing and furniture is as important as cleaning the person. Clothing should be cleaned in hot water and dried with hot heat. Items that cannot be machine washed, like toys, headphones, and helmets, should be cleaned by hand or sealed in plastic for approximately three weeks. Furniture can be covered with plastic drop cloths after vacuuming. Boil combs and brushes in water for 10 minutes or soak in a bleach solution.

The client may attach a social stigma, or intense feelings of anxiety or shame, to being infested with lice. It is important to assess for psychological and social concerns and intervene as needed. Advise the client that lice infestations are not a sign of being unclean. Lice prefer a clean surface for laying eggs. Lice are parasites that will find any host. If clothing and bedding is not routinely washed, however, the spread of the lice may be greater.

Community health nurses need to educate those affected in the prevention, detection and removal of lice from the individual and the environment, as well as the social and emotional concerns of acquiring lice. They need to arrange and follow up with inspection of family members, school, or work mates, who might have acquired lice from the client. They need to involve appropriate personnel if an outbreak is suspected in a public place. Records on who has been examined and treated, what locations have been treated, and what follow-up treatment has been completed must be kept, as well as information on additional cases that occur.

List your findings and conclusions:

Lice infestation

Nursing diagnoses:

00004 Risk for infection 00038 Risk for trauma (risk for skin) 00080 Ineffective family therapeutic regime management (risk for) 00081 Ineffective community therapeutic regime management (risk for) 00133 Chronic pain 00046 Risk for Impaired skin integrity 00118 Disturbed body image 00120 Risk for situational low self-esteem 00146 Anxiety

1. The nurse is reassuring a distract parent who’s child was found to have head lice at school. Which of the following does the nurse tell the parent is not a factor for contracting head lice? a. Head-to-head contact with an infested person b. Wearing the hat of an infested person c. Having unclean hair d. Sleeping in the bed of an infested person

2. When conducting telephone consultation with the parents of daycare children who may have been exposed to head lice, the nurse tells them that the most common symptom of lice infestation is a. Itching b. Peeling/scaling skin c. Swollen glands d. Hair loss

3. When conducting telephone consultation with the parents of daycare children who may have been exposed to head lice, the nurse tells them that lice move from host to host by a. Flying b. Crawling c. Jumping d. Burrowing

4. When bathing any client at a clinic that supports homeless people, the nurse knows the best way to dispose of the towel is a. Give it to the client to use to wipe down surfaces. b. Place it on the doorknob. c. Drop it into the dirty linen bag following institutional guidelines. d. Hold it (and all client linen) close to the body, to prevent touching other people with it, and carry it to the nearest laundry room or laundry hamper.

5. Which of the following is best for washing clothing and bedding when recovering from a lice infestation? a. Place clothing in a plastic bag for two days. b. Rinse clothing in vinegar. c. Rinse with cold water and hang to dry. d. Wash with soap and hot water and dry with hot heat.

6. When teaching parents how to treat a head lice infestation in their child, the nurse tells them that the following is accurate about lice infestations? a. It is sometimes easier to see the nits than it is to see the lice. b. Shampooing the hair once is enough to rid the client of lice. c. Lice always come back d. The house must be fumigated

7. An adolescent is sent to the school nurse by his teacher who noticed nits in the child’s hair while leaning over him to help with his work. The adolescent is very upset. Which of the following is an inaccurate nursing diagnosis? a. Risk for situational low self-esteem b. Anxiety c. Disturbed body image d. Uncleanliness 8. Which of the following is the most important follow-up step to ridding a client of head lice? a. Comb the nits out of the hair. b. Shampoo the hair every eight hours for the first day. c. Cut off hair with nits attached. d. Treat the itching with topical ointments.

9. Which of the following is not true about head lice? a. They live about 30 days. b. They live up to two weeks away from a host on an unused pillow. c They have wings. d. Eggs (nits) are not easily killed.

10. When examining a client for the presence of head lice a. Have the client bend over a white towel and shake the hair vigorously to dislodge nits and lice. b. Use a long needle to move the hair to search for nits. c. It is not necessary to wear gloves as there will be no contact with blood or bodily fluids. d. Wear gloves and use wooden applicator sticks to move the hair.